Ophthalmology Flashcards
Causes of papilloedema
- Space-occupying lesion: neoplastic, vascular
- Malignant hypertension
- Idiopathic intracranial hypertension
- Hydrocephalus
- Hypercapnia
- Hypoparathyroidism and hypocalcaemia
- Vitamin A toxicity
Eyelid problems
- Blepharitis: inflammation of eyelid margins typically leading to red eye
- Stye: infection of glands of eyelids
o Mx: hot compresses and analgesia - Chalazion (Meibomian cyst): retention cyst of Meibomian gland
- Entropion: in-turning of eyelids
- Ectropion: out-turning of eyelids
Differentials for painless acute red eye
o Conjunctivitis
o Episcleritis
o Subconjunctival haemorrhage
Differentials for painful acute red eye
o Acute angle closure Glaucoma
o Anterior uveitis
o Scleritis
o Corneal abrasions or ulceration
o Keratitis
o Foreign body
o Traumatic or chemical injury
o Endophythalmitis
o Dry eyes
Causes of acute visual loss
Optic nerve
- Anterior ischaemic optic neuropathy
- Optic neuritis
Retina
- Central retinal artery occlusion
- Central retinal vein occlusion
What is age related macular degeneration
Degeneration of central retina causing progressive deterioration in vision, often bilateral
Risk factors for macular degeneration
- Advancing age
- Smoking
- Family history (white or Chinese ethnic origin)
- CVD = Hypertension, Dyslipidaemia, Diabetes mellitus
- Obesity (poor diet low in vits and high in fat)
- Females
Classification of macular degeneration
- Dry (90%) = drusen (yellow round spots in Bruch’s membrane), slow progression
- Wet (10%) = choroidal neovascularisation, rapid progression
Presentation of macular degeneration
- Subacute onset of central visual field loss
- Reduction in visual acuity for near field objects
- Difficulties in dark adaptation with overall deterioration in vision at night
- Fluctuations in visual disturbance
- Photopsia (perception of flickering or flashing lights)
- Glare around objects
- Crooked or wavy appearance to straight lines (metamorphopsia)
- Visual hallucinations Charles-Bonnet syndrome
Examination of macular degeneration
- Amsler grid testing distortion of line perception
- Fundoscopy presence of drusen, fluid leakage or haemorrhage
- Atrophy of retinal pigment epithelium
- Degeneration of photoreceptors
- Scotoma (central patch of vision loss)
Investigations of macular degeneration
- Slit lamp microscopy + colour fundus photography
- Fluorescein angiography
- Ocular coherence tomography
Management of macular degeneration
- Refer to ophthalmology for assessment and management
- Zinc with vitamins A, C and E
- Stop smoking
- Blood pressure control
- Anti Vascular endothelial growth factors (ranibizumab, aflibercept, bevacizumab) for wet ARMD ± steroids
- Laser photocoagulation
What is primary open-angle glaucoma
- Optic nerve damage caused by raised intraocular pressure caused by blockage in aqueous humour
- Gradual increase in resistance to flow through trabecular meshwork
Risk factors for open-angle glaucoma
- Increasing age
- Family history
- Black ethnic origin
- Myopia (near-sightedness)
- Hypertension
- Diabetes mellitus
- Corticosteroids
Presentation of open-angle glaucoma
- May be asymptomatic
- Gradual onset of peripheral vision loss
- Fluctuating pain
- Headaches
- Blurred vision
- Halos around lights, particularly at night
Fundoscopy findings in open-angle glaucoma
Optic disc cupping
optic disc pallor
bayonetting of vessels
cup notching
disc haemorrhages
Investigations of open-angle glaucoma
- Non-contact tonometry (screening) measure pressure
- Goldmann applanation tonometry (GS)
- Slit lamp ‘cupping’
- Perimetry visual fields
- Gonioscopy peripheral anterior chamber configuration and depth
- Central corneal thickness
Management of open-angle glaucoma
- Started at intraocular pressure of 24 mmHg or above
- 1st line 360 degree selective laser trabeculoplasty
- 2nd line Prostaglandin analogue eye drops (latanoprost)
- 3rd line beta-blocker (timolol) eye drops, carbonic anhydrase inhibitor eye drops, sympathomietic eye drops
- Trabeculectomy considered in refractory cases
Side effects of prostaglandin analogue eye drops
eyelash growth, eyelid pigmentation, iris pigmentation (browning)
Prevention of open-angle glaucoma
Pts with positive family history should be screened annually from age 40
What is acute angle-closure glaucoma
- Optic neuropathy due to raised intraocular pressure
- Iris bulges forwards and seals off trabecular meshwork from anterior chamber preventing aqueous humour from draining
- Pressure builds in posterior chamber, pushing iris forwards and exacerbating angle closure
- MEDICAL EMERGENCY
Risk factors for angle-closure glaucoma
- Hypermetropia (long-sightedness)
- Pupillary dilatation
- Cataracts
- Lens growth associated with age
- Family history
- Female
- Chinese and East Asian ethnic origin
- Shallow anterior chamber
Triggers of angle-closure glaucoma
- Adrenergic medications (noradrenaline)
- Anticholinergic medications (oxybutynin and solifenacin)
- Tricyclic antidepressants (amitriptyline)
Presentation of angle-closure glaucoma
- Severely painful red eye
- Hazy cornea
- Decreased visual acuity blurred vision
- Symptoms worse with mydriasis (watching TV in dark room)
- Headache
- Haloes around lights
- Semi-dilated non-reacting oval pupil
- Corneal oedema results in dull or hazy cornea
- Hard eyeball on gentle palpation
- Systemic: N+V, abdo pain
Investigations of angle-closure glaucoma
- Tonometry elevated IOP (40-60 mmHg)
- Gonioscopy
Management of angle-closure glaucoma
- Urgent referral to ophthalmologist and immediate admission
- IV/oral acetazolamide reduces aqueous production
- Combination of eye drops direct parasympathomimetic (pilocarpine), iopidine drops
- Analgesia and antiemetic if required
- IV mannitol, timolol, dorzolamide, brimonidine
- Definitive: laser bilateral peripheral iridotomy
What is retinal detachment
Occurs when neurosensory tissue that lines the back of the eye comes away from its underlying pigment epithelium
Risk factors for retinal detachment
- Diabetes mellitus
- Myopia
- Age
- Previous surgery for cataracts
- Eye trauma (boxing)
Presentation of retinal detachment
- New onset floaters or flashes
- Sudden onset, painless and progressive visual field loss curtain or shadow progressing to centre of visual field from periphery
- Central visual acuity if macula involved
- Peripheral visual fields may be reduced
Examination of retinal detachment
- Swinging light test relative afferent pupillary defect if optic nerve involved
- Fundoscopy red reflex lost, retinal folds appear pale/opaque/wrinkled forms
Management of retinal detachment
- Urgent referral to ophthalmologist for assessment with slit lamp and indirect ophthalmoscopy for pigment cells and vitreous haemorrhage
- Surgery Vitrectomy + gas/oil tamponade/scleral buckle, cryotherapy to secure
- Laser photocoagulation
Complication of retinal detachment
Permanent visual loss
What is blepharitis
Inflammation of eyelid margins
Risk factors for blepharitis
Rosacea
Causes of blepharitis
- Meibomian gland dysfunction
- Seborrhoeic dermatitis/staph infection
Presentation of blepharitis
- Symptoms usually bilateral
- Grittiness and discomfort, particularly around eyelid margins
- Eyes may be sticky in the morning
- Crusts and scales on eyelashes
- Eyelid margins may be red
- Swollen eyelids may be seen in staph blepharitis
- Styes and chalazions mor common
- Secondary conjunctivitis may occur
Management of blepharitis
- Softening lid margin using hot compresses twice a day
- Lid hygiene
o Mechanical removal of debris from lid margins
o Cotton wool buds dipped in cooled boiled water and baby shampoo
o Sodium bicarbonate in cooled boiled water - Artificial tears for symptoms relief
Causes of optic neuritis
- Multiple sclerosis
- Other: sarcoidosis, Syphilis, diabetes
Presentation of optic neuritis
- Unilateral decrease in visual acuity over hrs or days
- Poor discrimination of colours red desaturation
- Pain worse on eye movement
- Relative afferent pupillary defect
- Central scotoma
Investigation of optic neuritis
MRI brain and orbits with gadolinium contrast
Management of optic neuritis
High dose steroids
What is keratitis
Inflammation of cornea
Causes of keratitis
- Bacterial: staph aureus, pseudomonas aeruginosa (contact lens wearers)
- Fungal
- Amoebic: acanthamoebic keratitis (soil or contaminated water)
- Parasitic: onchocercal keratitis (river blindness)
- Viral: herpes simplex
- Environmental: photokeratitis, exposure keratitis, contact lens acute red eye (CLARE)
- Mechanical or trauma
- Chemical
Presentation of keratitis
- Red eye: pain and erythema
- Photophobia
- Foreign body, gritty sensation
- Hypopyon
- Blurred vision
Management of keratitis
- Same-day Referral of contact lens wearers for slit lamp assessment
- Stop using contact lens until symptoms fully resolved
- Topical antibiotics: quinolones
- Cycloplegic for pain relief: cyclopentolate
Complications of keratitis
- Corneal scarring
- Perforation
- Endophthalmitis
- Visual loss
Causes of conjunctivitis
- Bacterial staph, gonoccocus
- Viral adenovirus
- Allergic
Presentation of conjunctivitis
- Unilateral/bilateral red, bloodshot eyes
- Itchy or gritty sensation
- Purulent discharge bacterial
o Typically worse in morning when eyes may be stuck together - Clear/serous discharge viral
o Associated with dry cough, sore throat, blocked nose, tender preauricular lymph nodes
Management of conjunctivitis
- Usually resolves without Tx after 1-2 wks
- Good hygiene to avoid spreading
o Avoid sharing towels or rubbing eyes
o Regularly washing hands - Avoid using contact lenses
- Cleaning eyes with cooled boiled water and cotton wool can help clear discharge
- Antibiotic eye drops: Chloramphenicol or fusidic acid
- <1m old need urgent ophthalmology review
- Antihistamines if allergic conjunctivitis
What is anterior uveitis
Idiopathic inflammation of iris and ciliary body
Risk factors for anterior uveitis
- Young, white males
- HLA-B27 ankylosing spondylitis
- IBD
- Sarcoidosis
- Behcet’s disease
- Infection shingles, toxoplasmosis, TB, syphilis, HIV
Presentation of anterior uveitis
- Acute onset
- Red, painful and watery eye
- Photophobia
- Blurred vision
- Lacrimation
- Ciliary flush (ring of red spreading outwards)
- Mild reduction in visual acuity
Investigation for anterior uveitis
Slit lamp examination
o Keratic precipitates
o Hypopyon (white cells, pus and debris)
o Irregular pupil
o Flare = inflammatory protein
o Posterior synechiae
Management of anterior uveitis
- Urgent review by ophthalmology
- Cycloplegics (Atropine, cyclopentolate)
- Steroids eye drops
What is Periorbital cellulitis
Infection of soft tissues anterior to orbital septum but not orbit
Presentation of periorbital cellulitis
- Acute onset red, swollen, painful eye
- Fever
- Partial or complete ptosis of eye due to swelling
- Orbital signs absent
- No pain on eye movements
Investigations for periorbital cellulitis
- Bloods CRP, FBC, blood cultures
- Swab discharge
- Contrast CT of orbit
Management of periorbital cellulitis
- Referral to ophthalmology for assessment
- Oral Abx (co-amoxiclav)
- Surgical drainage
- May require admission for observation
What is orbital cellulitis
- Infection affecting fat and muscles posterior to orbital septum, within the orbit but not involving the globe
- MEDICAL EMERGENCY
Risk factors for orbital cellulitis
- Childhood (mean age of hospitalisation 7-12 yrs)
- Previous sinus infection
- Lack of Haemophilus influenzae type b vaccination
- Recent eyelid infection/insect bite on eyelid (periorbital cellulitis)
- Ear or facial infection
- Trauma
Causes of orbital cellulitis
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Staph aureus
- Haemophilus influenzae B
Presentation of orbital cellulitis
- Unilateral rapid onset erythema and swelling around eye
- Severe ocular pain
- Visual disturbance (blurred vision, diplopia, reduction in colour vision)
- Ophthalmoplegia/ pain with eye movements
- Eyelid oedema and ptosis
- Chemosis, proptosis
- Systemic: fever, headache, malaise
- Drowsiness +/- N+V in meningeal involvement (rare)
Examination of orbital cellulitis
- Reduced visual acuity
- Afferent pupillary defect
- Proptosis (foreword movement of eyeball)
- Dysmotility
- Reduce periorbital sensation
Investigations of orbital cellulitis
- FBC WBC elevated, raised inflammatory markers
- CT with contrast inflammation or orbital tissues deep to septum, sinusitis
- Blood culture and microbiological swab to determine organism
Management of orbital cellulitis
- Admit for IV antibiotics (ceftriaxone with flucloxacillin and metronidazole)
- May require surgical drainage if abscess forms
Complications of orbital cellulitis
- Blindness
- Intracranial abscesses
What is episcleritis
Acute onset of inflammation in the episcleral of one or both eyes, idiopathic collagen vascular disorder
Associations of episcleritis
- IBD
- Rheumatoid arthritis
Presentation of episcleritis
- Painless red eye
- Watering and mild photophobia
- Injected vessels are mobile when gentle pressure applied to sclera
Investigation for episcleritis
Phenylephrine drops blanches conjunctival and episcleral vessels but not scleral
Management of episcleritis
- Conservative – self-limiting
- Artificial tears
Risk factors for scleritis
- Rheumatoid arthritis
- SLE
- Sarcoidosis
- Granulomatosis with polyangiitis
- Zoster
- Post-operative
Presentation for scleritis
- Red painful eye severe dull deep ache
- Watering
- Photophobia
- Gradual decrease in vision
- Blue sclera
Investigation for scleritis
Phenylephrine application
Management of scleritis
- Same day assessment by ophthalmologist
- Oral NSAIDs
- Oral prednisolone
- Immunosuppressive drugs for resistant cases
What is diabetic retinopathy
Blood vessels in retina are damaged by prolonged exposure to hyperglycaemia
Presentation of diabetic retinopathy
Asymptomatic vision loss
Classification of diabetic retinopathy
- Non-proliferative diabetic retinopathy
o Mild microaneurysms
o Moderate microaneurysms, blot haemorrhages, hard exudates, cotton wool spots and venous beading
o Severe blot haemorrhages plus microaneurysms in 4 quadrants, venous beading in 2 quadrates, intraretinal microvascular abnormality - Proliferative diabetic retinopathy
o Retinal neovascularisation
o Fibrous tissue forming anterior to retinal disc
o Vitreous haemorrhage - Diabetic Maculopathy
o Macular oedema
o Ischaemic maculopathy
Management of diabetic retinopathy
- Maculopathy VEGF inhibitors (ranibixumab, bevacizumab)
- Non-proliferative observe, close monitoring, careful diabetic control
- Proliferative panretinal laser photocoagulation, intravitreal VEGF inhibitors
- Vitreoretinal surgery in severe disease
- Macular oedema intravitreal implant containing dexamethasone
- Control BP/diabetes
Complications of diabetic retinopathy
- Retinal detachment
- Vitreous haemorrhage
- Rubeosis iridis neovascular glaucoma
- Optic neuropathy
- Cataracts
- Vision loss
Risk factors for hypertensive retinopathy
- Smoking
- Hyperlipidaemia
Chronic/malignant hypertension
Presentation of hypertensive retinopathy
- Silver wiring/copper wiring walls of arterioles become thickened and sclerosed causing increased reflection of light
- Arteriovenous nipping arterioles cause compression of veins where they cross
- Cotton wool spots ischaemic and infarction causing damage to nerve fibres
- Hard exudates damaged vessels leaking lipids into retina
- Retinal haemorrhages
- Papilloedema/disc swelling
Classification of hypertensive retinopathy
Keither-Wagener
- Stage 1 – mild narrowing of arterioles
- Stage 2 – focal constriction of blood vessels ad AV nicking
- Stage 3 – cotton-wool patches, exudates and haemorrhages
- Stage 4 – papilloedema
Risk factors for corneal ulcer
- Contact lens use
- Vitamin A deficiency
Causes of corneal ulcer
- Bacterial keratitis
- Fungal keratitis
- Viral keratitis herpes simplex, herpes zoster
- Acanthamoeba keratitis (associated with contact lens use
Presentation of corneal ulcer
- Eye pain
- Photophobia
- Watering of eye
- Focal fluorescein staining of cornea
Risk factors for central retinal artery occlusion
- Older age
- Family history
- Smoking
- Alcohol consumption
- Hypertension
- Diabetes
- Poor diet
- Inactivity
- Obesity
Causes of central retinal artery occlusion
- Thromboembolism = atherosclerosis
- Arteritis = temporal arteritis
Presentation of central retinal artery occlusion
- Sudden, painless unilateral visual loss
- Relative afferent pupillary defect
- Fundoscopy = ‘Cherry red’ spot on pale retina
Management of central retinal artery occlusion
- Refer immediately to ophthalmology
- Immediate management
o Ocular massage
o Removing fluid from anterior chamber to reduce intraocular pressure
o Inhaling carbogen to dilate artery
o Sublingual isosorbide dinitrate - Treat underlying condition
o Temporal arteritis high dose prednisolone - Can try intraarterial thrombolysis
Risk factors for central retinal vein occlusion
- Hypertension
- High cholesterol
- Diabetes
- Smoking
- Glaucoma
- Systemic inflammatory conditions SLE
- Increasing age
- Polycythaemia
Presentation of central retinal vein occlusion
- Sudden painless loss of vision
- Fundoscopy flame and blot haemorrhages ‘stormy sunset’, optic disc oedema, macula oedema
Investigations for central retinal vein occlusion
- FBC anaemia
- ESR inflammatory disorders
- Blood pressure hypertension
- Serum glucose diabetes
Management of central retinal vein occlusion
- Immediate referral to ophthalmology
- Laser photocoagulation for retinal neovascularisation
- Intravitreal steroids dexamethasone intravitreal implant
- Anti-VEGF therapies for macular oedema ranibizumab, aflibercept or bevacizumab
Complications of central retinal vein occlusion
Neovascularisation
Causes of corneal abrasions
- Trauma
- Contact lenses
- Foreign bodies
- Fingernails
- Eyelashes
- Entropion
Presentation of corneal abrasions
- Painful red eye
- Foreign body sensation
- Watery eye
- Blurring vision
- Photophobia
Investigations of corneal abrasions
- Fluorescein stain
- Slit lamp examination
- XR/CT
Management of corneal abrasions
- Same-day assessment by ophthalmologist if potentially sight-threatening
- Remove foreign bodies
- Simple analgesia
- Lubricating eye drops
- Abx eye drops chloramphenicol
- Follow up after 24 hrs
- Chemical abrasions immediate irrigation for 20-30 mins and urgent referral to ophthalmology
- Uncomplicated corneal abrasions heal over 2-3 days
Complications of corneal abrasions
- Pseudomonas infection from contact lens
- Chemical abrasions severe damage and loss of vision
Types of cataracts
- Nuclear (old age)
- Cortical (wedge shaped spokes
- Posterior subcapsular (steroid use)
Risk factors for cataracts
- Increasing age
- Smoking
- Alcohol
- Diabetes
- Steroids
- Hypercalcaemia
- Myotonic dystophy
Presentation of cataracts
- Asymmetrical
- Very slow reduction in visual acuity
- Progressive blurring of vision
- Change of colour of vision with colours becoming more brown/yellow
- ‘Starbursts’ can appear around lights, especially at night
- Loss of red reflex
Management of cataracts
Cataract surgery (phacoemulsification) – replace with artificial lens
Complications of cataracts surgery
- Endophthalmitis – inflammation of inner contents of eye
o Tx: intravitreal Abx injected into eye - Posterior capsule opacification
o Tx: YAG laser - Posterior capsule rupture
- Retinal detachment
What is a subconjunctival haemorrhage
Common condition where one of the small blood vessels within conjunctiva ruptures and release blood into space between sclera and conjunctiva
Risk factors for subconjunctival haemorrhage
- Hypertension
- Bleeding disorders = thrombocytopenia
- Whooping cough
- Medications warfarin, NOACs, antiplatelets
- Non-accidental injury
Causes of subconjunctival haemorrhage
- Heavy coughing, sneezing
- Weight lifting
- Straining when constipated
- Trauma to eye
Presentation of subconjunctival haemorrhage
- Patch of bright red blood underneath conjunctiva
- Painless
- Not affect vision
Management of subconjunctival haemorrhage
- Resolves spontaneously without Tx in around 2 weeks
- Treat any underlying risk factors
- Foreign body sensation lubricating eye drops
Causes of a dilated pupil (mydriasis)
- Congenital
- Stimulants (cocaine)
- Anticholinergics (oxybutynin)
- Trauma
- Third nerve palsy
- Holmes-Adle syndrome
- Raised intracranial pressure
- Acute angle-closure glaucoma
Causes of a constricted pupil (miosis)
- Horner syndrome
- Cluster headaches
- Argyll-Robertson pupil (neurosyphilis)
- Opiates
- Nicotine
- Pilocarpine
